Improving Hand Hygiene Compliance and Reducing the Hawthorne Effect in Long-Term Care


Washing your hands is the single most effective way of controlling the spread of diseases. It is assumed that healthcare professionals and everyone working in a healthcare setting know to wash their hands before and after resident contact, but this isn’t always true. Healthcare Acquired Infections (HAI’s) are largely attributed to failures in hand hygiene (HH) practices. One way to battle HAI’s is to quantify what your staff are actually doing when HH should be performed. This requires gathering data by observing your staff at specific HH moments. This data can then be analyzed, and decisions can be made about how to increase adherence to HH practices.

Issue: The Hawthorne effect is the alteration of behavior by the subjects of a study due to their awareness of being observed. Historically, with paper-based hand hygiene audits, individuals being observed have been found to modify an aspect of their behavior in response to their awareness of being observed. This has been shown to artificially inflate the hand hygiene compliance rates within healthcare settings. “This is especially the case when we perform hand hygiene audit with a clip board, making it very obvious to the front-line staff” (1).

(1) PAPER TO PHONE – MAKING HAND HYGIENE AUDITING EASY AND REDUCING THE HAWTHORNE EFFECT. Murtuza et al. (Halton Healthcare). IPAC Canada Journal of Infection Control Winter 2021

Project: To capture the true compliancy of Hand Hygiene rates in the healthcare setting HealthConnex introduced a mobile Hand Hygiene auditing application with an integrated AI system. Designed for use within both acute care and post-acute care settings the application supports front-line staff conducting audits using mobile devices and uses integrated AI to evaluate the quality of the audits to support a true compliance rate. Audits can be captured using a mobile device or a computer and is based on the standard 4 moments of hand hygiene. Auditors observe the worker washing their hands or using alcohol-based hand sanitizers with a timer feature to document the duration of the observation. Integrated AI tools within the HealthConnex software evaluate the quality of the audit for proper compliance. Additionally, the tool provides education opportunities for staff to review audits after completion with the worker(s). The data is accessible on a mobile web platform that provides administrators an overarching view of their facility(s) and unit(s) to review compliance.

Results: HealthConnex has taken this process to the next level both in data collection and the analysis of it by measuring the quality of the HH performed. Working with our clinical partners we identified opportunities to analyze the data collected further and identify areas for improvement and education. Using our integrated AI metrics, HealthConnex automatically flags non-compliant data for the user(s) to analyze.

In the first 1-2 months Clients will see a decrease in compliant (wash and rub observations which met the set criteria) observations. This is not a bad outcome; it identifies the true compliance at the facility and provides the ability to review and put into place a performance improvement plan through education and auditor intervention. After 2-3 months Clients have seen an increase in hand hygiene compliance with statistically significant data they can trust.

Furthermore, by removing the paper-based audits, auditors (clinicians and administrators) spend less time manually entering Hand Hygiene observations into Excel and running pivot tables to calculate compliance rates and can perform more quality audits in less time. This means they can focus more time on providing service and care to residents.

Education is the best way to create a culture of HH compliance and it is the simplest and most effective way to decrease HAI’s. Having the data to know where to target education it will ensure your facilities are the safest they can be.